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A nurse is caring for four clients. Which of the following clients is at the greatest risk for falling?

A.

A client who has diminished vision ambulating in well-lit areas

B.

A client who received a diuretic 30 min ago

C.

A client who requires assistance with ambulation

D.

A client who had a tonic-clonic seizure 2 hr ago

Answer and Explanation

The Correct Answer is D

A.    A client with diminished vision ambulating in well-lit areas may be at risk for falling but is not at the greatest risk among the options provided.
B.    A client who received a diuretic 30 min ago may experience orthostatic hypotension, which can increase the risk of falling, but it is not the highest risk.
C.    A client who requires assistance with ambulation is generally at a lower risk than a client who has recently experienced a tonic-clonic seizure.
D.    A client who had a tonic-clonic seizure 2 hr ago is at the greatest risk for falling due to potential residual weakness, disorientation, or postictal state following the seizure.
 


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Related Questions

Correct Answer is A

Explanation

A) The client should hold the cane on the unaffected side to provide support for the affected side, which is weaker. Holding the cane on the affected side does not offer the necessary support and balance needed during ambulation, indicating a need for further teaching.
B) Keeping two points of support on the ground, such as one foot and the cane or both feet, is a safe practice that ensures stability while ambulating, so no further teaching is necessary for this action.
C) Advancing the cane before moving the unaffected leg is the correct technique. The cane should be moved first, followed by the affected leg, and then the unaffected leg, to maintain balance and support.
D) Supporting weight on both legs when moving the cane forward is appropriate as it provides a stable base and prevents the client from falling, indicating that the client understands the correct use of the cane.

Correct Answer is C

Explanation

A. TENS does not primarily work by providing distraction from pain.

B. While relaxation may be a secondary effect, the primary mechanism of TENS is not to elicit a relaxation response.
C. TENS works by modulating the transmission of the pain impulse, disrupting pain signals from reaching the brain.
D. TENS does not primarily work by promoting increased circulation to the painful area.

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